Wednesday, March 25, 2009

The Witching Hour


It was hard to believe that less than two hours ago our 40-bed Emergency Department was nearly full. We managed to admit or discharge nearly all of our patients in that short time. Only two occupants remained: one was a 17-year-old habitual "cutter" who had gone off her bipolar medication; we had stitched her up and she was just waiting for Daddy to come get her. The other patient was a harmless professional drunk whom we named "Otis." Otis was currently sleeping off his two-bottles-of-Old Crow dinner and getting IV vitamins.

Nurses and ER Techs had been busy for the previous hour, putting the department back together after a particularly vicious night with a patient demographic chock full drunks, punks, and bipolar funks. Hooray for Welfare Check Weekend. Yay.

Having completed the tasks associated with my particular section, and having no patients, I sat down at my station, stretched, yawned obnoxiously, and pulled out my copy of Patrick O'Brian's The Golden Ocean.

The housekeeper (a truly endearing gentleman named Moe, who is believed to be around 800 years old) arrived in the department riding his Super-Awesome Floor-Cleaning Vehicle. The machine functioned pretty much like a Zamboni. It kept our special rubberized floors nice and clean- until, of course, we walked on them with our filthy-soled shoes.

The Zamboni was universally hated by the nursing staff, and rumor had it that the machine was manufactured somewhere in the lowest plane of Hell by the devil himself. As innocuous as the thing appeared to be (it kind of looked like a prematurely-delivered SmartCar), its true sinister origins were revealed by its noise. The thing emitted a constant, bellowing screech reminiscent of a skinned banshee with a pitchfork up its arse. Its nightly rounds created an environment that was about as therapeutic as trench warfare.

Moe drove his infernal steed with a great big grin on his face and a cold gleam of bloody-minded determination in his eye. No puny mortals would deter Moe from his mission as he screamed through the Emergency Department at the blinding speed of 0.5MPH. Moe made it clear that he would not waver from his intended course; we had best get out of the way and the devil take the hindmost. He emphasized his point by honking the Zamboni's horn.

Oh yes, it had a horn. It sounded exactly like one salvaged from a 1967 Volkswagen Beetle- specifically, a Beetle that had just been discovered after forty years of being buried in the slimy muck of a freshly-drained swamp:


It was a soft, plaintive, mournful sound that carried through the early-morning air and evoked from Otis a slurred "WazzahellizZAT!?"- immediately after which the Sirens of Bacchus recaptured him with their wine-fueled song and returned him to snoring, slobbering, farting oblivion.

Having completed its infernal rounds, the hell-spawned steed with Moe at the reins retreated to the black pit from whence it came. A traumatized silence, similar to that which is experienced after witnessing a bad accident, ensued.


The change in the atmosphere was palpable. Staff slowly drifted towards the two large resuscitation (or "thrash") rooms that remained active- to one of which I was assigned. I put away my book, got up from my desk, went into my thrash room, and methodically prepared for a patient who did not yet exist. I pulled out a sheet and laid it on the stretcher, placed two disposable absorbent "chucks" on it, and elevated the bed to waist level. I pulled out an assortment of IV needles, skin prep supplies, and blood collection tubes, neatly arraying them on a stainless steel rolling table called a "Mayo stand." I brought out a Foley catheter kit, nasogastric tube supplies, and other sundry invasive instruments. I set up three suction points and checked for proper function. I pulled out a Bag-Valve-Mask and hung it over an oxygen flowmeter. One of the ER Techs casually parked a portable EKG machine outside the room.

This is the ritual of the Witching Hour.

The Witching Hour is what we call that period of time, roughly from five-ish to six-ish in the morning, when most heart attacks occur. It has to do with rising cortisol levels that occur during the body's sleep/wake transition cycle. It is unnecessary to go to great lengths in describing the pathophysiology behind the phenomenon. It can simply be explained thus: There is something about waking up that really gets a sick heart pissed off. And the heart, perhaps like no other organ, has a magnificent way of letting its owner know that it is really pissed off- especially if said heart has been abused by decades of overeating, smoking, substance abuse, and laziness. (Or sometimes it's just crappy genetics. Ask Jim Fixx, a 1970s-era marathon runner who was in ludicrously excellent shape. Oh, wait... he's dead. Heart attack. I think his last words were, "Oh, crap. You gotta be friggin' kidding!")


The medic phone rang. The MD took report, handed the run sheet to Mindy the Charge Nurse, and returned to his computer. Mindy turned around and quite by coincidence (I swear, really!) ran into me.

"Howdy," said I.

"Gee, I know how you hate these things, but can I trouble you to take this one, pretty please?" Mindy asked with a flat and rather sarcastic tone of voice. She batted her eyelashes.

I drawled, "Well, okay ma'am, since you asked real nice and all..." and took the sheet from Mindy's hands with a wink and a crooked grin. She snorted, rolled her eyes, and walked away shaking her head and mumbling something to herself about "code junkies."

I returned to the thrash room to recheck my preparations. I turned to my colleagues and recited the details from the run sheet: A 46-year-old man woke up at 0500 with crushing chest pain, nausea, lightheadedness, and cold sweats. He had no known medical conditions (until now). He was hypotensive and bradycardic (this raised a few eyebrows in the room). He was to arrive in 5 minutes. (Why medics choose to wait until they are only five minutes away to tell us they are enroute with a super-sick patient is a perpetual mystery to us.)

Having provided the background, I then gave each colleague a set of specific assignments to perform throughout the process. I would act as Primary RN.

The role of the Primary RN is highly management-intensive. My responsibilities as a primary nurse are to assign, oversee, document, and insure the completion of all nursing and tech-related tasks as long as the patient is in my care. Additionally, when a task was completed I must either provide a new task or release that RN or tech from the room in order to keep the area clear of all nonessential persons. I am to insure that the administration of all medications, the call times and arrival times of other specialists and departments, all interventions by medical and nursing staff, and the patient’s responses to those interventions are accurately and succinctly documented. Additional tasks for which the primary nurse is responsible include obtaining accurate information regarding the patient’s health and medication history and verifying any allergies to medication, the type of reactions, and the severity thereof. On top of all of this, the primary nurse is responsible for reporting all adventitious findings to the MD, carrying out preparation of the patient for transfer to the receiving department, providing an accurate ‘handoff’ report to the receiving nurses, and insuring that the patient arrives at his or her next stage safely and with all possible speed. I am also responsible for maintaining an environment that facilitates calm and clear communication. I do not allow cross-room talk, elevated voices, or needless chatter. While the physician "ran" the code, I ran the room; I was Chief of the Boat.

Because of the extreme depth of my involvement with the oversight of those matters, I typically will not lay a hand on my patient for the first time until five to ten minutes after arrival- and sometimes not at all. I do try to introduce myself at the soonest opportunity, ask the patient how he feels, and explain what is happening. But until the patient has been stabilized, this will be the extent of our relationship. More often than not, I will slip unknown and phantom-like in and out of my patient's life.


When the patient arrived, we were gowned and ready. I took station off to the patient's side where I had counter space and could see the monitor and every machine in the room. The other RNs and Techs transferred the patient onto our stretcher, stripped him, gowned him, and covered him up. He was fully hooked up to the monitor and a full set of initial vital signs was written down in less than a minute. A second large-bore IV was started. The MD stood at my right side, and while we both listened to the medic's report, I kept my eyes on the process.

Something about the patient's EKG was just funky. Clearly, the man was having a heart attack, but it wasn't the front part of the heart that was damaged. The MD looked at it, looked at the patient's monitor, and instructed the tech to perform a posterior-placement EKG. A minute later, it all made sense. The focus of the MI involved most of the backside of the heart- something we don't see all that often. It also explained the patient's bradycardia and low blood pressure.

This kind of MI really sucks for the patient, because all those great medications that would ease his horrific pain and protect his heart from stress (nitroglycerin, morphine, and beta blockers) would also cause his blood pressure and heart rate to drop like a cow off the high dive. So he was going to have to hurt for a little while longer.


The monitor alarmed. The patient went into ventricular tachycardia. CPR commenced while the defibrillator charged up. Per MD order, an initial shock of 300 joules was delivered. The patient jerked, sat bolt upright in bed and bellowed "Holy crap! What the hell...?" He blinked a few times, then settled himself back down.

"Well, that worked," Mindy said dryly.

The patient's heart returned to a perfusing (though still ominous) rhythm. Breathing resumed among the team members.


The cardiologist arrived in the room and received a briefing by the ER MD. He approached the patient and introduced himself.

"Sir, I am Doctor So-and-So. You're having a heart attack."

"Ya think!?" gasped the patient.

"We're going to take to look at which artery is causing your heart attack and try to unplug it so you can get better. There's a small chance that it could cause other problems like a stroke or a worse heart attack, but that doesn't happen very often. Do you consent to allow us to do the procedure?"

"Oh, what the hell. My dance card's empty. Sure."

The cardiologist looked at our documentation and walked out to see if the Cath Lab crew had arrived. He returned to the room and asked me if, rather than have the Cath Lab come get the patient, we could bring the patient so that his gang could complete setup. I told him we could. Mindy picked an RN and tech to package the patient up and get him going while I completed the documentation and made sure all vital signs were uploaded into the computer. I called the Cath Lab chief RN and gave her a report as my patient was wheeled out of the room.

The cardiologist found that a posterior branch of the patient's Right Coronary artery had occluded nearly 100 percent, and he was able to clear the jam. The patient stabilized immediately and was whisked up to CCU to begin a pretty rapid recovery. Door-to-balloon time: under thirty minutes. National standard: ninety minutes. (Does my team kick ass? Heck yeah!)


My thrash room was finally squared away, my documentation was complete, and after making the rounds to thank my colleagues I again settled down to my book. Once again a welcome silence settled over the department- broken only once by a single loud, lonnnnnnnnnnnnng belch, courtesy of Otis.